Thirty years ago the British physician, Julian Tudor-Hart published his famous ‘inverse care law’: ‘those who most need medical care are the least likely to get it.’

Modern pharmaceutical research is playing Dr Hart’s law out on a macabre global scale. While the debilitating diseases of the poor – such as malaria, tuberculosis and sleeping sickness – have few or no treatments, the drug companies are busy working on cures for a ballooning set of ‘made-up’ diseases of the rich and privileged. There are now drugs for toenail fungus, ‘pre-hypertension’ and bedwetting; for compulsive shopping and gambling ‘addiction’. The yawning extremes between the research priorities in our two worlds get larger – and weirder.

Daniel Berman used to work for Big Pharma and saw at firsthand how companies created ‘markets’ for new drugs. Now the Geneva-based co-ordinator with Médecins Sans Frontières’ Access to Essential Medicines Campaign, Berman describes the example of drugs being created to treat normal changes to the prostate that develop as men age.

‘It used to be that when men age, they have to go to the bathroom during the night a couple times and that was considered a part of ageing, and that was no big deal. But this problem was turned into a disease by the drug manufacturer.’ Because the company was developing a drug to deal with ‘the condition’, they needed to convince both doctors and patients that this aspect of ageing required drug treatment. And they hired people like Daniel Berman to help spin that message.

To create ‘new’ diseases Berman says drug companies hire public relations agencies and work with academics. ‘You find a professor working in a university and fund that professor to write a book, or to do a media tour around the country. Or you find a public figure, a sports figure or an actor, to go around and meet and work with journalists, and to do work with public forums, so you literally create this need.’

Creating a market that will reduce men’s nocturnal trips to the bathroom is what modern drug research is all about. Finding lifesaving treatments for poor customers can be left to the philanthropists. When drug company executives schmooze with investors, they talk about diseases in terms of market potential and how well a disease area ‘performs’. Remarking on rising rates of obesity or diabetes, investors and drug makers can hardly contain their mutual glee. The dark clouds of potentially dire public health consequences are seen in terms of their silver linings – generating legions of new customers. Drug companies claim they need a large market to recoup their research and development costs. But the top drug companies throw nearly three times more money at marketing and promotion than they do at basic R&D.

Who needs cures?
Many people still believe that medicine is a noble pursuit, dedicated to curing humankind’s ills. But the reality is that ‘cure’ is passé. According to Alex Hittle, a biotech analyst at AG Edwards in St Louis: ‘We sometimes joke that when you’re doing a clinical trial, there are two possible disasters. The first disaster is if you kill people. The second disaster is if you cure them. The truly good drugs are the ones you can use chronically for a long, long time.’

Over the past decade we’ve seen the pharmacologizing of everyday life at a breathtaking pace – the rampant and colonizing forces of the drug industry, sometimes slyly, sometimes overtly, reshaping the normal ups and downs of everyday life and turning them into market opportunities. Among the range of invented or trivial ‘conditions’ for healthy, paying customers are male pattern baldness, wrinkles, unwanted facial hair, erectile dysfunction and persistent sadness (not to be confused with depression).

The big money, however, is not in niche complaints that can get turned into diseases, but in taking risk factors for future possible diseases and turning them into conditions that are targets for drug treatment. So lifestyle conditions common to our 21st century world – obesity, cholesterol or high blood pressure – become fair game.

This ‘pharmacologization’ of human health is an outgrowth of ‘medicalization’ which the late US author Lynn Payer discussed in her 1992 book Disease Mongers. She wrote that more benign ways of characterizing ordinary ailments (and simpler, less costly remedies) are ignored or marginalized when pharmaceutical manufacturers start to colonize an area of human health. In order to build demand for their products and services they will sponsor awareness-raising campaigns to make common conditions look as severe and widespread as possible.

Two of the best examples are the drug industry’s response to blood pressure and mental health.

The antidepressant market is large and fluid. Everything from critically debilitating depression to mild anxiety could be ripe for medication. Large companies, fiercely fighting for customers, are constantly seeking to expand the definition of depression and so increase the numbers who need treatment. In such a milieu, tragic events like 11 September 2001 are seen as marketing opportunities, as excuses to flog more treatments for ‘post traumatic stress disorder’.

Eli Lilly, facing the end of its patented blockbuster, Prozac, recently relaunched the famous drug with a fancy new pink makeover and a nifty name – Sarafem. This ‘Prozac in Pink’ is now marketed as a treatment for severe PMS (now reshaped into the more medical-sounding PMDD – Pre-Menstrual Dysphoric Disorder).

Drug giant GlaxoSmithKline has taken paroxetine (Paxil in North America, Seroxat in Europe) and had it approved to treat what we used to call social phobia or shyness, now reclassified as ‘social anxiety disorder’ (SAD). Barry Brand, Paxil’s product director, told the journal Advertising Age: ‘Every marketer’s dream is to find an unidentified or unknown market and develop it. That’s what we were able to do with social anxiety disorder.’1

The creation of disease categories in psychiatry has not been without controversy. San Diego-based psychiatrist Loren Mosher, in his letter of resignation to the American Psychiatric Association, said: ‘Psychiatrists have become the minions of drug company promotions.’ He blasted the drug-industry shaped definitions of mental disease: ‘No longer do we seek to understand whole persons in their social contexts – rather we are there to realign our patients’ neurotransmitters.’

Managing ‘risk’
Disease prevention in healthy people with so-called ‘risk factors’ like high blood pressure or high cholesterol is another lucrative market. These measurable markers are carefully defined to encompass vast numbers of healthy people.

High blood pressure ‘medicalized’ becomes ‘hypertension’, now the leading pharmaceutically treated ‘condition’ in the world. Of course anti-hypertensive drugs do help people who have high blood pressure or who have had a previous heart attack or stroke. But the drugs get pushed on healthier, younger people with very little evidence as to their impact on health or longevity.

In 1999 when the World Health Organization held meetings to set high-blood-pressure guidelines, Big Pharma made sure their interests were well represented. What resulted were recommendations not based on the best evidence, but based on the best support for pharmaceutical treatments.

Drug companies also support patient groups or programmes that are warm to their interests such as the National High Blood Pressure Education Program in the US. Earlier this year this group sounded warnings about ‘pre-hypertension’, which ratcheted down the definition of high blood pressure from 140 over 90 to 120 over 80, thus turning millions more people with ‘borderline’ high blood pressure into medication-needing patients overnight.

The trend of big pharmaceutical companies morphing into nothing more than marketing organizations is reflected in data from the drug makers themselves. The Pharmaceutical Research and Manufacturers Association (PhRMA) in the US reports that, since 1995, R&D staff of US brand-name drug companies have decreased by 2 per cent, while marketing staff have increased by 59 per cent. Currently, 22 per cent of staff are employed in R&D, while 39 per cent are in marketing.2

And the marketers are getting involved earlier in a drug’s development to make sure things turn out as profitable as possible. Kim White, the managing director of the New York office of Ogilvy Public Relations, says that the pre-launch marketing strategies for many of the new mass-market medications will include company-funded education of doctors and consumers long before the drug is launched. The job of the PR company, she says, is to ‘beat the drum’, to use conferences and journals to get doctors and consumers buzzing about a new drug coming down the pipe.3

Often, patient groups or medical foundations – so-called ‘third-party’ organizations – are funded to participate in these campaigns, silently orchestrated by drug company marketing departments and their PR houses.

I’m reminded of Willie Sutton, who spent his career robbing banks, escaping from jail, only to rob again. When he was asked at the end of his career why he kept on robbing banks, his nonchalant reply was: ‘Because that’s where the money is.’ That could explain why drug companies spend so freely on marketing and disease mongering instead of lifesaving research.

Alan Cassels is a drug policy researcher in Victoria, BC, Canada. He led a team of researchers which produced Canada's first evaluation of the quality of media reporting of prescription drugs.

1 David Goetzl in Advertising Age, 26 June 2000.2 Deborah Socolar and Alan Sager, ‘Pharmaceutical marketing and research spending: the evidence does not support PhRMA’s claims’, Boston University School of Public Health.3 Interview with author.

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